Functional decline
Red flags
- Rapid decline over days (vs weeks-months) - think acute illness/delirium, not baseline frailty progression
- New inability to perform a previously intact ADL (e.g. transfers, toileting) - marker of an acute driver, not just "getting old"
- Weight loss, new incontinence, falls clustering with the decline
- Signs of neglect/inadequate care at home
- Carer breakdown or expressed inability to cope - urgent social crisis, not just medical
Differential by mechanism
Acute/subacute medical
- Infection (often occult - UTI only if symptomatic, pneumonia, skin), delirium
- New cardiac (heart failure, arrhythmia), stroke/TIA
- Metabolic (hyponatraemia, hypothyroidism, B12 deficiency, hypercalcaemia)
- Medication effect (new sedative, dose change, polypharmacy)
Subacute/chronic progressive
- Dementia progression
- Depression (pseudo-dementia, apathy, self-neglect)
- Progressive frailty/sarcopenia
- Chronic disease progression (COPD, heart failure, CKD, Parkinson's)
- Malnutrition
Situational/social
- Carer stress/breakdown, loss of a carer (bereavement)
- Inadequate services relative to need
- Elder abuse or neglect
Focused history
- Timeline - baseline function 2-4 weeks ago vs now (collateral essential)
- ADLs (basic - washing, dressing, toileting, transferring, continence, feeding) and IADLs (shopping, finances, medications, transport, cooking)
- Falls, weight loss, mood, cognition, sleep
- Full medication review including recent changes and OTC/complementary use
- Social supports - who is at home, services in place, carer wellbeing
- Nutrition and appetite
- Screen for pain, constipation, urinary symptoms as covert drivers
Focused examination
- Vital signs, hydration, weight/BMI trend
- Cognitive screen (MMSE/MoCA), delirium screen (4AT)
- Mood screen (geriatric depression scale)
- Gait, balance, muscle bulk/strength (sarcopenia)
- Cardiorespiratory, abdominal (constipation, retention), skin (pressure areas, hygiene)
- Home environment observation where possible (or via OT/social work report)
Investigation strategy
- Bloods: FBE, UEC, calcium, glucose, TFT, B12/folate, CRP, LFT, vitamin D
- MSU only if symptomatic; CXR/blood cultures if infection suspected
- ECG
- Cognitive and mood assessment tools as above
- Comprehensive Geriatric Assessment (CGA) - the organising framework for anyone with unexplained functional decline
- Home/OT functional assessment, falls risk assessment
Management
Sequence
1. Identify and treat the acute driver if present (infection, drug effect, metabolic, cardiac)
2. Comprehensive Geriatric Assessment to map the full contributing picture where decline is unexplained or multifactorial
3. Address each domain found, rather than a single diagnosis-and-treat approach
Domains to address
- Medical: optimise chronic disease control, deprescribe where appropriate (anticholinergic/sedative burden)
- Functional: physiotherapy/OT for mobility, strength, ADL retraining and aids
- Nutritional: dietitian input, treat reversible malnutrition causes
- Cognitive/mood: treat delirium, screen/manage depression, dementia work-up if progressive
- Social: carer support, respite, aged care service escalation (home care package review, consider residential care assessment if safety cannot be maintained)
- Environmental: home modification, equipment
Goals of care
- Establish realistic goals with patient/family - restoration to prior baseline vs new baseline given acute illness or progressive disease
- Avoid therapeutic nihilism - most acute functional decline has a reversible component worth pursuing before accepting a new lower baseline
- Early rehabilitation referral - delay increases risk of the decline becoming permanent (deconditioning)
Traps
- Labelling decline as "just old age" without a systematic search for a reversible driver
- Missing depression/pseudo-dementia as a treatable cause of apparent cognitive and functional decline
- Treating asymptomatic bacteriuria as the cause instead of continuing the work-up
- Under-recognising carer breakdown as the acute precipitant requiring urgent social intervention
- Delaying rehabilitation referral - functional reserve is lost quickly and regained slowly
- Not screening for elder abuse/neglect when the trajectory or social context is inconsistent
Talk track
Establish the timeline against a known baseline, then search systematically for an acute reversible driver (infection, drugs, metabolic, cardiac, delirium, depression) before attributing decline to disease progression alone. Comprehensive Geriatric Assessment organises the work-up across medical, functional, cognitive, nutritional and social domains, and each identified problem gets its own targeted intervention rather than one diagnosis driving everything.
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